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Saturday, July 13, 2019

Retrospective #147:Obesity is a Disease (for billing purposes)

The New York Times article begins, “The American Medical Association has officially designated
obesity as a disease…” This ties in nicely with my last two columns, #146, “Medicare
to Pay for Obesity Counseling” and #145, “Gastric Bypass vs. Medical Therapy,”
and the next, #148, “Obesity, a Condition of Genetic Susceptibility?”

The AMA call was a tough one for a variety of reasons, not least of which
is that there is no general agreement in the scientific community on the
definition of “disease.” The Times
piece explains, “Those arguing against it [the designation of obesity as a
disease] say that there are no specific symptoms associated with it, and that
it is more of a risk factor for other conditions than a disease in its own
right.” In making the designation, the AMA at their convention overrode a
recommendation against doing so by a committee that had studied the matter for
a year.

The committee said that “obesity should not be considered a disease
mainly because the measure usually used to define obesity, the body mass index
(BMI), is simplistic and flawed.” The committee argued that “some people with a
BMI above the level that usually defines obesity are perfectly healthy while
others below it can have dangerous levels of body fat and metabolic problems
associated with obesity.” The committee wrote, “Given the existing limitations
on BMI to diagnose obesity in clinical practice, it is unclear that recognizing
obesity as a disease, as opposed to a ‘condition’ or ‘disorder,’ will result in
improved health outcomes.”

According to an article in Forbes
by Chris Conover, the AMA finessed the BMI business by “simply defining obesity
as an excess of body fat sufficiently large to cause reduced health and
longevity.” According to Conover, “they answered the question of ‘should we
consider obesity a disease’ largely on utilitarian grounds – that the social
benefits of doing so will outweigh the costs.” Conover then went on to brilliantly
demolish that argument.

Conover said, “the AMA is (late) to the party.” The National Institutes
of Health declared in 1985 that “obesity is a serious health condition that
leads to increased morbidity and mortality.” And the National Heart, Lung and
Blood Institute commented in 1995 that “obesity is a multifactorial chronic
disease developing from multiple interactive influences of numerous factors.” And
he cites the Surgeon General’s 2001 Call to Action to Prevent and Decrease
Overweight and Obesity. And Michelle Obama’s 2009 Taskforce on Childhood Obesity.
Even the IRS considered obesity to be a disease, and Medicaid jumped on the
bandwagon in 2010. Medicare has too, for counseling and surgery, but not for
reimbursement for weight loss drugs. Why then is the
AMA defining obesity as a disease now?

If we needed one, The Times
gives us a clue to a motive for the AMA action. One advocate commented, “I
think you will probably see from this, physicians taking obesity more
seriously, counseling their patients about it.” And it noted, “…it could help improve reimbursement for obesity drugs,
surgery and counseling. Two new obesity drugs – Qsymia…and Belviq…have entered
the market in the last year,” and “Qsymia has not sold well for a variety of
reasons, including poor reimbursement…”

At the Huffington Post,
self-described policy wonk and blogger Larry Cohen enthusiastically huffed, “After
the AMA announcement, some members of Congress introduced a bill to expand
Medicare reimbursements for weight-loss drugs and weight-reduction treatment.”
The Washington lobbyists jumped in exaltation.

And then The Times piece cracks
the door open just a bit with, “Some doctors say that people do not have full
control over their weight,” and “that
‘medicalizing’ obesity by declaring it a disease would define one-third of
American as being ill and could lead to more reliance on costly drugs and
surgery rather than lifestyle changes. But, if the treatment is merely treating a symptom (obesity), rather
than the underlying disease, doesn’t that solidify a wrong treatment
modality for a non-existent disease? The AMA finessed that too by saying that
obesity was a “multimetabolic and hormonal disease state” that leads to
unfavorable outcomes like type 2 diabetes and CVD.”

Neither The Times nor the AMA
subscribes to Gary Taubes’s Alternative Hypothesis that INSULIN RESISTANCE, the metabolic disregulation that characterizes Type
2 diabetes, is what leads to fat
accumulation. (obesity).

About Me

I was diagnosed a Type 2 diabetic in 1986. I started a Very Low Carb diet (Atkins Induction) in 2002 to lose weight. I didn’t realize at the time that it would put my diabetes in clinical remission, or that I would be able to give up almost all of my oral diabetes meds. I also didn’t understand that, as I lost weight and continued to eat Very Low Carb, my blood lipids would dramatically improve (doubling my HDL and cutting my triglycerides by 2/3rds) and that my blood pressure would drop from 130/90 to 110/70 on the same meds.
Over the years I changed from Atkins to the Bernstein Diet (designed for diabetics) and, altogether lost 170 pounds. I later regained some and then lost some. As long as I eat Very Low Carb, I am not hungry and I have lots of energy. And I no longer have any of the indications of Metabolic Syndrome.
My goal, as long as I have excess body fat, is to remain continuously in a ketogenic state, both for blood glucose regulation and continued weight loss. I expect that this regimen will continue to provide the benefits of reduced systemic inflammation, improved blood lipids and lower blood pressure as well.